Clinical characteristics of SARS-CoV-2 vaccine-related acute appendicitis.

BACKGROUND: In a large nationwide mass vaccination setting, the SARS-CoV-2 vaccine was recently linked to myocarditis, lymphadenopathy, herpes zoster infection and appendicitis. We aimed to examine the characteristics and management of SARS-CoV-2 vaccine-related acute appendicitis. METHODS: We performed a retrospective cohort study in a large tertiary medical centre in Israel. All patients presenting with acute appendicitis within 21 days of receiving their SARS-CoV-2 vaccination (PCVAA group) were compared with patients who presented with acute appendicitis not related to the vaccination (N-PCVAA group). RESULTS: We reviewed the records of 421 patients with acute appendicitis from December 2020 to September 2021; 38 (9%) patients presented with acute appendicitis within 21 days of receiving their SARS-CoV-2 vaccination. Patients in the PCVAA group were older than those in the N-PCVAA group (mean 41 ± 19 yr v. 33 ± 15 yr, respectively, p = 0.008), with male predominance. More patients were managed nonsurgically during the pandemic than before the pandemic (24% v. 18%, p = 0.03). CONCLUSION: With the exception of older age, the clinical characteristics of patients presenting with acute appendicitis within 21 days of receiving the SARS-CoV-2 vaccination did not differ from those of patients who presented with acute appendicitis not related to the vaccination. This finding suggests that vaccine-related acute appendicitis is similar to "classic" acute appendicitis.

Circulating Cell-free DNA in Patients With Acute Biliary Pancreatitis: Association With Disease Markers and Prolonged Hospitalization Time-A Prospective Cohort Study.

OBJECTIVE: To evaluate cfDNA as an indicator of pancreatitis severity. BACKGROUND: Acute pancreatitis severity scores have limited proficiency, and are complex and challenging to use clinically. Elevation of circulating cfDNA concentration has been shown to be associated with hospital length of stay (LOS) and mortality. METHODS: In a prospective study, cfDNA concentration was measured by a simple fluorometric test, at admission and for 2 consecutive days, in patients with acute biliary pancreatitis (ABP). Ranson and APACHE II scores were used as measures of pancreatitis severity. Hospital LOS and mortality were used as outcome measures. RESULTS: Seventy-eight patients were included. Patients with severe disease according to Ranson's Criteria (n = 24) had elevated median admission cfDNA compared to patients with mild disease (n = 54, 2252ng/ml vs 1228 ng/ml, P < 0.05 ). Admission cfDNA levels correlated with Ranson and APACHE II scores and markers of bile duct obstruction. LOS did not differ between patients with mild and severe disease according to Ranson and APACHE II scores. Patients with cfDNA at 24 hours concentrations above the cutoff value of healthy patients (>850 ng/ml) had a significantly longer LOS compared to those with normal cfDNA levels ( P < 0.001 ). CONCLUSIONS: cfDNA, measured by a rapid simple assay, proved a valuable early marker of severity in ABP with clear advantages for prediction of LOS over Ranson and APACHE II. Measurement of cfDNA has the potential to be an effective practical approach to predict the course of ABP and should be further evaluated in larger trials.

Intra-abdominal pressure may be elevated in patients with open abdomen after emergent laparotomy.

PURPOSE: To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who were left with open abdomen and temporary abdominal closure after laparotomy, during the first 48 h after admission. METHODS: A cohort study in a single ICU in a tertiary care hospital. All adult patients admitted to the ICU after emergent laparotomy for acute abdomen or trauma, who were left with temporary abdominal closure (TAC), were included. Patients were followed up to 48 h. IAP was routinely measured at 0, 6, 12, 24, and 48 h after admission to ICU. RESULTS: Thirty-nine patients were included, 34 were operated due to acute abdomen and 5 due to abdominal trauma. Seventeen patients were treated with skin closure, 13 with Bogota bag, and 9 with negative pressure wound therapy (NPWT). Eleven patients (28.2%) had IAP of 15 mmHg or above at time 0, (mean pressure 19.0 ± 3.0 mmHg), and it dropped to 12 ± 4 mmHg within 48 h (p < 0.01). Reduction in lactate level (2.4 ± 1.0 to 1.2 ± 0.2 mmol/L, p < 0.01) and increase in PaO2/FiO2 ratio (163 ± 34 to 231 ± 83, p = 0.03) were observed as well after 48 h. CONCLUSIONS: This is the first large report of IAP in open abdomen. Elevated IAP may be measured in open abdomen and may subsequently relieve after 48 h.

Intermittent cycles of remote ischemic preconditioning augment diabetic foot ulcer healing.

The morbidity and mortality caused by diabetic foot ulcer (DFU) are still significant. Conservative treatment of DFU is often ineffective. Treatment modalities using stem cells directly into the DFU or systematically have been introduced recently. Ischemic preconditioning (IPC) has been proved to be a cheap, simple, and safe method which can augment stem cells number in the peripheral blood circulation. This study's purpose was to test whether IPC can improve DFU healing. Forty diabetic patients were enrolled and divided into study and control groups. All patients received their regular treatment. The study group patients received in addition brief, transient cycles of IPC while the control group patients received a sham procedure only. The procedure was repeated every 2 weeks to complete a follow-up period of 6 weeks. The ulcers were photographed to measure wound area, and the degree of granulation tissue was assessed. No serious adverse events were noted. Twenty-two patients from the study group and 12 from the control group completed the entire follow-up. The ratio of patients who reached complete healing of their ulcer was 9/22 (41%) in the study group compared with 0/12 (0%) in the control group, p = 0.01. Furthermore, the mean remaining ulcer area at the end of the follow-up was significantly smaller in the study group, 25 ± 6% of the initial area vs. 61 ± 10% in the control group, p = 0.007. The degree of granulation increased after one cycle of treatment in 8/24 (33%) study patients compared to 3/16 (19%) in the control group, p = 0.47. Remote, repeated IPC significantly improves the healing of DFU. This simple, safe, inexpensive treatment method should be considered to be routinely applied to diabetic patients with DFU in addition to other regular treatment modalities.

[Plasma DNA measurement as a biomarker of cancer].

BACKGROUND: Carcinoembryonic antigen (CEA) and CA 15-3 serve as biomarkers in the two prevalent cancers of the colon and breast, respectively. However, their sensitivity for screening is tow. Circulating DNA has been suggested as a potential marker. We developed a fluorometric method which enables an easy, fast and reliable DNA measurement. This manuscript presents the results of our experiments to evaluate the significance of DNA measurements in breast and colon patients. METHODS: Patients who had been diagnosed with early stages of colon or breast cancer were recruited into a prospective study. Blood samples were withdrawn for the determination of CEA, CA 15-3 (according to the type of cancer) and circulating DNA concentrations prior to any therapeutic intervention. Control DNA Levels were determined in blood samples of healthy volunteers. RESULTS: Mean circulating DNA in patients with colon cancer was higher than in control subjects [798+409 ng/ml vs. 308 +/- 256 ng/ml, p<0.0001. High DNA concentrations were identified in 40% of colon patients compared with 28% with increased CEA levels. Mean DNA levels among breast cancer patients was higher than the control group [1060 +/- 670.9 ng/mt vs. 376.2 +/- 244.1 ng/ml, p=0.0001]. High DNA concentrations were identified in 53% of breast cancer patients compared with 9% with increased CA 15-3 levels. CONCLUSION: A novel simple, rapid, cheap and reliable fluoroscopic method was used to determine circulating DNA levels in the blood of breast and colon cancer patients. Increased DNA concentrations were found in the blood of early cancer patients. This method demonstrates a better sensitivity compared with the traditional markers.

Effectiveness of a two-tiered trauma team activation system at a level I trauma center.

PURPOSE: Many trauma patients who are transported to our level I trauma center have minor injuries that do not require full trauma team activation (FTTA). Thus, we implemented a two-tiered TTA system categorizing patients into red and yellow code alerts, indicating FTTA and Limited TTA (LTTA) requirements, respectively. This study aimed to assess the effectiveness of this triage tool by evaluating its diagnostic parameters (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), undertriage and overtriage) and comparing injury severity between the two groups. METHODS: A retrospective cohort study of patients admitted to a Level I trauma center. Characteristics compared between the red and yellow code groups included demographics, injury severity, treatments, and hospital length of stay (LOS). Calculating the diagnostic parameters was based on Injury Severity Score (ISS) and the need for life-saving surgery or procedures. RESULTS: Significant differences in injury severity indicators were observed between the two groups. Patients in the red code group had a higher ISS and New Injury Severity Score (NISS), a lower Glasgow Coma Score (GCS), Revised Trauma Score (RTS), and probability of survival. They had a longer hospital LOS, a higher Intensive Care Unit (ICU) admission rate and required more emergency operations. The Sensitivity of the triage tool was 85.2%, specificity was 55.6%, PPV was 74.2%, NPV was 71.5%, undertriage was 14.7%, and overtriage was 25.7%. CONCLUSION: The two-tiered TTA system effectively distinguish between patients with major trauma who need FTTA and patients with minor trauma who can be managed by LTTA.

Banded One-Anastomosis Gastric Bypass (BOAGB) for Patients Living with Obesity and Extreme Obesity: A Single Institution's Experience.

BACKGROUND: The prevalence of patients suffering from extreme obesity (body mass index (BMI) ≥ 50) has significantly increased over the past three decades, surpassing the rise in the general population of overweight patients. Weight loss outcomes after bariatric surgery in patients suffering from extreme obesity are less favorable, with a higher incidence of weight regain. Variations of existing bariatric procedures have been proposed to address this issue. One such variation is adding a gastric band to limit the expansion of the newly created pouch. Limited data exist regarding the effectiveness of this procedure, called the banded one-anastomosis gastric bypass (BOAGB) procedure, compared to other bariatric procedures. METHOD: In this retrospective study, we compared all patients who underwent the BOAGB procedure at the Bariatric Surgery Unit in our Medical Center with a postoperative follow-up of at least 1 year with patients who underwent a one-anastomosis gastric bypass (OAGB) or sleeve gastrectomy (SG) procedures. Data collected included demographics, comorbidities, surgical outcomes, complications, and postoperative quality-of-life assessments. RESULTS: One hundred eleven patients were enlisted to our study during the relevant study period-24 patients underwent the BOAGB procedure, 43 underwent OAGB, and 44 underwent a SG. Lost to follow-up beyond 30 days was 9% (at 1-year post-surgery, we were able to establish contact with 101 patients). The pre-op BMI was significantly higher in the BOAGB group compared to the other procedures. Additionally, a higher prevalence of diabetes was observed in the BOAGB group. The duration of surgery was significantly longer for the BOAGB procedure. No significant differences were found in surgical complications. Overall, all procedures resulted in significant excess weight loss (EWL) or change in BMI, improvement in comorbidities, and improved quality of life postoperatively. CONCLUSIONS: The BOAGB procedure, like OAGB and SG, demonstrated favorable weight loss outcomes and weight maintenance 1 year postoperatively without significant differences between the procedures. The BOAGB procedure is relatively new, with good bariatric outcomes and a favorable safety profile. Long-term study is needed to evaluate these various bariatric procedures' efficacy further.

High occurrence of perianal abscess among Bedouin compared to Jews in the southern region of Israel.

BACKGROUND: This study assessed the ethnic differences of perianal abscess between Bedouin and the general population in southern region of Israel. Israeli-born Arabs have much less colorectal cancer than Israeli-born Jews. It is not clear whether other colorectal diseases have the same ethnic occurrence. METHOD: This is a retrospective case series of patients who had perianal abscess. Patients' demographics, managements and course of disease were analyzed. RESULTS: Bedouin male constituted 29.7% of all patients, while they constitute only 15.7% of the population relative risk of 2.27 (p< 0. 001). 16.4% of the patients experienced perianal abscess recurrence. 39% of the males with recurrent abscess formation were Bedouin, relative risk of 1.8 (p<0. 001). CONCLUSION: Bedouin males have high relative risk to develop perianal abscess. Bedouin males as others with first recurrence have high relative risk for recurrence. Thus for both groups of patients, there is an indication to operate in order to treat the abscess and coexisting fistula.

The Long-term Effect of Standardized Anal Dilatation for Chronic Anal Fissure on Anal Continence.

PURPOSE: For the past several decades, internal anal sphincterotomy has generally been considered to be the standard operation for an anal fissure. However, wound complications inherent in this operation forced surgeons to look for an alternative form of treatment. The aim of our study was to evaluate the long-term outcome of anal dilatation for chronic anal fissure, especially possible negative impact on anal sphincter function. METHODS: The study was approved by the local Institutional Review Board and given a waiver of written consent. A phone call survey was undertaken among a group of consecutive patients who had an anal dilatation by standardized technique for chronic anal fissure for the period between 2000 and 2016. The survey included medical, obstetrical and surgical-related data, Wexner fecal incontinence score, recurrence of the anal fissure, and the need for additional medical intervention. Five hundred 48 patients were identified after limitations of age, concomitant pathology, and procedures that were applied to the hospital computerized database. Eighty-five patients (group A) agreed to participate in the survey and 463 patients did not. RESULTS: There were no differences between groups in demographic information and medical records data; therefore, group A may well represent a satisfactory sample of the whole group. The interval between the procedure and the survey was 6.8 ± 2.7 years. The Wexner incontinence score was 0 in 94% of patients. CONCLUSION: Anal dilatation, performed in a systematic and standardized way, has a successful outcome with no complications and has no clear long-term negative impact on anal sphincter function.

The effect of steroid treatment on whiplash associated syndrome: a controlled randomized prospective trial.

PURPOSE: There is significant evidence in the literature that low or relatively low cortisol concentrations near the time of an accident are associated with more severe forms of whiplash-associated disorders. We hypothesized that treating patients that were involved in a motor vehicle accident with hydrocortisone would alleviate the incidence and severity of these disabling disorders. METHODS: A prospective, randomized, double-blind, placebo-controlled clinical trial. Blunt trauma patients that underwent a motor vehicle crash were allocated into a study group that received a single bolus of hydrocortisone and a control group that received saline. The patients were followed for 1 month. The incidence and severity of whiplash associated disorder, functional disturbances, and post-traumatic stress disorder were compared between the two groups. The analyses were repeated for sub-divisions into groups of high and low admission cortisol. RESULTS: The more severe forms of whiplash-associated disorders on the day of accident were associated with low cortisol levels; mean cortisol concentration of the lower grade of whiplash patients (13.09 ± 7.35 µg%) was higher than that of whiplash syndrome of the severe forms (8.33 ± 3.45 µg), p = 0.001. There were no differences between study and control groups regarding whiplash-associated disorders, functional tests, and severity of stress disorder 1 month after the accident. Significant differences were evident between high and low cortisol sub-groups. Those who had low cortisol level on admission and received hydrocortisone had worse outcomes. CONCLUSION: Steroid treatment of patients with whiplash might be harmful to those who present with low cortisol concentrations (< 9.5 µg/dL). TRIAL REGISTRATION: Clinical Trials: Association between low cortisol levels and whiplash syndrome. Date of registration: March 18, 2014. Date the first participant was enrolled: May 10, 2014. TRIAL REGISTRATION NUMBER: NCT02090309. URL: https://clinicaltrials.gov/ct2/show/NCT02090309 .

Stomach pH before vs. after different bariatric surgery procedures: Clinical implications for drug delivery.

Stomach pH may vary following bariatric surgery, with implications for drug delivery/bioavailability. Yet, this parameter has not been studied. In this work, gastric content was aspirated from patients before, immediately after, and the day after different bariatric procedures, and pH was immediately measured. Compared to pre-surgery (1.8), pH was increased one day after one-anastomosis gastric bypass (OAGB) and sleeve gastrectomy (LSG) by 3-4 pH units; pH immediately after these procedures was in between the other 2 time points. Post-OAGB pH was significantly higher than post-LSG (6.4 and 4.9, respectively). Prior adjustable gastric band did not significantly alter baseline pH. We then performed drug dissolution studies of the antiplatelet drugs dipyridamole and aspirin, mimicking pre-surgery, post-LSG and post-OAGB conditions, implementing our pH results and other relevant physiological parameters. Dipyridamole, a weak base, completely dissolved (100% of dose) under pre-surgery conditions, while dissolution was hampered under post-LSG (5%) and post-OAGB (0.25%) conditions, due to solubility limit. Aspirin was not released from enteric-coated tablet under pre-surgery or post-LSG gastric conditions, however, >75% dissolved within 15 min under post-OAGB gastric conditions, indicating potential failure of enteric coating, depending on the bariatric procedure. In conclusion, special care should be taken when using pH-dependent drugs and drug products after bariatric surgery, and the use of pH-independent formulations should be preferred. Overall, this research revealed the interim gastric pH after different bariatric procedures, and potentially important effects on post-bariatric oral drug delivery and treatment.

Regulation of adenosine system at the onset of peritonitis.

BACKGROUND: Adenosine, a potent regulator of inflammation, is produced under stressful conditions due to degradation of ATP/ADP by the ectoenzymes CD39 and CD73. Adenosine is rapidly degraded by adenosine deaminase (ADA) or phosphorylated in the cell by adenosine kinase (AK). From four known receptors to adenosine, A(1) (A(1)R) promotes inflammation by a G(i)-coupled receptor. We have previously shown that A(1)R is up-regulated in the first hours following bacterial inoculation. The aim of the current study is to characterize the inflammatory mediators that regulate adenosine-metabolizing enzymes and A(1)R at the onset of peritonitis. METHODS: Peritonitis was induced in CD1 mice by intraperitoneal injection of Escherichia coli. TNFalpha and IL-6 levels were determined in peritoneal fluid by enzyme-linked immunosorbent assay. Adenosine-metabolizing enzymes and the A(1)R mRNA or protein levels were analyzed by quantitative PCR or by Western blot analysis, respectively. RESULTS: We found that CD39 and CD73 were up-regulated in response to bacterial stimuli (6-fold the basal levels), while AK and ADA mRNA levels were down-regulated. Cytokine production and leukocyte recruitment were enhanced (2.5-fold) by treatment with an A(1)R agonist (2-chloro-N(6)-cyclopentyladenosine, 0.1 mg/kg) and reduced (2.5-3-fold) by the A(1)R antagonist (8-cyclopentyl-1, 3-dipropylxanthine, 1 mg/kg). In contrast to lipopolysaccharide, IL-1, TNF and IFNgamma, only low IL-6 levels (0.01 ng/ml), in the presence of its soluble IL-6R (sIL-6R), were found to promote A(1)R expression on mesothelial cells. In mice, administration of neutralizing antibody to IL-6R or soluble gp130-Fc (sgp130-Fc) blocked peritoneal A(1)R up-regulation following inoculation. CONCLUSION: Bacterial products induce the production of adenosine by up-regulation of CD39 and CD73. Low IL-6-sIL-6R up-regulates the A(1)R to promote efficient inflammatory response against invading microorganisms.

Can cortisol levels predict the severity of acute whiplash-associated disorders?

BACKGROUND: The exact underlying mechanism of whiplash-associated disorders still remains obscure. Central sensitization of the brain to painful stimulus and disturbances in the hypothalamic-pituitary-adrenal axis has been suggested to contribute to the development of whiplash-associated disorders. Although cortisol is a well-known factor in the acute stress response and its effects on chronic pain sensation were studied, information is lacking regarding the relation between acute phase cortisol concentrations and the intensity of whiplash-associated disorders. The aim of this prospective observational study was to investigate the relationship between acute serum cortisol concentrations and the severity of whiplash-associated disorders. METHODS: 55 patients enrolled in the study and they answered a pertinent questionnaire. A blood sample was drawn to determine serum cortisol concentration. RESULTS: The mean cortisol concentration of the whiplash-associated disorder score 2-3 patients was significantly lower compared to the whiplash-associated disorder score 1 patients, 9.5 ± 6.9 vs. 13.22 ± 8.3 µg% (p = 0.02). The mean cortisol concentrations increased significantly from mild through moderate to serious grade of severity of accident as perceived by the patient, 9.64 ± 4.82, 11.59 ± 6.85, 17.39 ± 12.1 µg% (p = 0.02). CONCLUSIONS: The study supports the possibility that cortisol plays a role in the development of whiplash-associated disorders. Low or relatively low cortisol concentrations might be associated with more severe forms of the disorder.

Cell-free DNA concentration in patients with clinical or mammographic suspicion of breast cancer.

Mammography has a crucial role in the detection of breast cancer (BC), yet it is not limitation-free. We hypothesized that the combination of mammography and cell-free DNA (cfDNA) levels may better discriminate patients with cancer. This prospective study included 259 participants suspected with BC before biopsy. Blood samples were taken before biopsy and from some patients during and at the end of treatment. cfDNA blood levels were measured using our simple fluorescent assay. The primary outcome was the pathologic diagnosis of BC, and the secondary aims were to correlate cfDNA to severity, response to treatments, and outcome. Median cfDNA blood levels were similar in patients with positive and negative biopsy: 577 vs. 564 ng/ml (p = 0.98). A significant decrease in cfDNA blood level was noted after the following treatments: surgery, surgery and radiation, neo-adjuvant chemotherapy and surgery, and at the end of all treatments. To conclude, the cfDNA level could not be used in suspected patients to discriminate BC. Reduction of tumor burden by surgery and chemotherapy is associated with reduction of cfDNA levels. In a minority of patients, an increase in post-treatment cfDNA blood level may indicate the presence of a residual tumor and higher risk. Further outcome assessment for a longer period is suggested.

Enhancing limb salvage by non-mobilized peripheral blood angiogenic cell precursors therapy in patients with critical limb ischemia.

BACKGROUND: Stem cell therapy has been proposed to enhance the salvage of critically ischemic limbs. OBJECTIVE: Assess the efficacy and safety of the implantation of non-mobilized peripheral blood angiogenic cell precursors (NMPB-ACPs) in patients with critical limb ischemia (CLI) who were poor candidates for standard revascularization treatment options. MATERIAL AND METHOD: Six patients with CLI due to the infrapopliteal artery occlusive disease were included in the present study. Intramuscular injections of NMPB-ACPs were administered in the ischemic limbs. The efficacy was evaluated by clinical outcomes, ankle brachial index, toe brachial index, and computerized tomographic angiography. RESULTS: There was no evidence of local or systemic complication related to the procedure. Five patients (83.3%) had clinically significant improvement of adequate circulation at the distal limb for the complete healing. Four of them had complete healing of ischemic ulcers and stumps of toe amputation. However one patient with adequate granulation tissue at the stump of the left first toe amputation subsequently suffered from severe foot infection originating from the other toes and eventually underwent below knee amputation. There was no improvement of circulation at the distal limb after the administration of NMPB-ACPs in one patient (16.7%) who eventually underwent major amputation. CONCLUSION: The preliminary result of NMPB-ACPs therapy may be safe and provide benefits in the improvement of circulation in patients with CLI. A larger controlled trial is required to ascertain these preliminary results.

Increased Paracetamol Bioavailability after Sleeve Gastrectomy: A Crossover Pre- vs. Post-Operative Clinical Trial.

Oral drug bioavailability may be significantly altered after laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure worldwide. Paracetamol (acetaminophen) is the post-bariatric analgesic/antipyretic drug of choice. In this work we studied and analyzed the LSG effects on systemic bioavailability and pharmacokinetics of paracetamol after oral administration of solid vs. liquid dosage form. A 4-armed, pharmacokinetic, crossover trial was performed in patients enrolled for LSG. Single paracetamol dose (500 mg), as caplet (n = 7) or syrup (n = 5), was administered before vs. 4-6 months post-LSG. Bioavailability was enhanced after LSG; in the caplet groups, average AUC0-t increased from 9.1 to 18.6 µg·h/mL with AUC0-t difference of 9.5 µg·h/mL (95% CI 4.6-14.5, p = 0.003). Cmax increased from 1.8 (95% CI 1.2-2.5) to 4.2 µg/mL (3.6-4.8) after LSG (p = 0.032). In the syrup groups, AUC0-t increased from 13.4 to 25.6 µg·h/mL, with AUC0-t difference of 12.2 µg·h/mL (95% CI 0.9-23.5, p = 0.049). Cmax changed from 5.4 (95% CI 2.5-8.4) to 7.8 µg/mL (6.1-9.6), and systemic bioavailability was complete (102%) after the surgery. Overall, decreased paracetamol exposure in obesity, with recovery to normal drug levels (caplet) or even higher (syrup) post-LSG, was revealed. In conclusion, attention to paracetamol effectiveness/safety in obesity, and after bariatric surgery, is prudent.

The Impact of Technical Surgical Aspects on Morbidity of 984 Patients after Sleeve Gastrectomy for Morbid Obesity.

BACKGROUND: To evaluate early complications after LSG in regard of staple line reinforcement (SLR), bougie size, previous bariatric surgery and surgeon experience. METHODS: A retrospective cohort study of LSG patients at the Soroka University Medical Center (SUMC). Data was collected from digitalized database. RESULTS: Nine hundred eighty-four LSG cases were performed by three surgeons. Seventy-eight complications were observed (7.9%): 44 mild (4.5%) and 34 severe (3.4%). Over-sewing of staple line was performed in 689 cases (76.2%), and no SLR in 217 cases (24.0%) without significant impact on mild or severe early morbidity. Bougie size 36 Fr or smaller was used in 635 cases (73.0%) without significant differences in early complications compared to 235 cases (27.0%) with larger bougie. LSG, as revision bariatric surgery, was performed in 273 cases (27.7%). Concomitant removal of a gastric band was performed in 199 of these cases (72.9%). History of silastic ring vertical gastroplasty (SRVG) was recorded in 10 cases (1.0%). Previous bariatric surgery was a significant risk factor for early mild complications (OR = 1.14, p value = 0.02), but not for severe ones (OR = 0.79, p value = 0.09). Concomitant removal of gastric band did not affect this result. The risk for mild complication was significantly reduced with surgeon experience achieving 100 cases. CONCLUSIONS: SLR or bougie size is not affecting LSG morbidity, but previous bariatric history and surgeon experience are significant factors for early mild complications.

Military Weapon Injury Among Illegal Immigrants at the Southern Border of Israel: A Single Level I Trauma Center Series.

This article describes the characteristics of injuries of illegal immigrants admitted to a Level I trauma center after being shot at the southern border of Israel. This is a retrospective descriptive study. Some of the variables were compared to a group of soldiers who sustained penetrating injury at the same region where the illegal migrant were injured. The study includes 162 patients. The lower body absorbed a higher percentage of the injuries (61 %). The hospitalization time is longer for the migrant patients compared to the soldiers (13 ± 2 vs. 3 ± 0.3 days p = 0.0001). This study on wounded immigrants shows that a conjoint military and civilian system can result in favourable outcomes. The manuscript is an attempt to bring this unique situation, its type of injuries, and the difficulties of the health system in coping with it, to the notice of all authorities that may address a similar challenge.

Cell-free deoxyribonucleic acid as a prognostic marker of bowel ischemia in patients with small bowel obstruction.

BACKGROUND: Patients with strangulation small bowel obstruction are at a high risk for serious morbidity and mortality due to ischemic bowel. Measuring serum, cell-free deoxyribonucleic acid levels could help recognize early cell death. Our hypothesis was that small bowel ischemia or necrosis is associated with increases in serum cell-free deoxyribonucleic acid and that recovery is associated with a decrease in cell-free deoxyribonucleic acid levels. METHODS: A prospective cohort study in addition to standard treatment of patients admitted with a diagnosis of small bowel obstruction. The participants were divided into groups depending on the presence of ischemic or necrotic bowel according to operative and clinical outcome. Clinical data and serum-based cell-free deoxyribonucleic acid levels were compared. Cell-free deoxyribonucleic acid levels from these 2 groups also were compared with a third group of healthy controls. RESULTS: In the study, 58 patients were enrolled, and 18 patients (31%) underwent operation. During the operative procedure, ischemic or necrotic bowel was found in 10 cases (17%). Serum levels of cell-free deoxyribonucleic acid at the time of admission in the ischemic/necrotic bowel group were increased compared with patients with well perfused or spontaneously recovered bowel (P = .03). Cell-free deoxyribonucleic acid levels decreased on the day after admission in 88% of the nonoperated patients. No significant differences were found in demographics, medical background, imaging performed, and cause of obstruction nor in clinical admission data. CONCLUSION: Surgeons currently rely on imprecise clinical parameters, including degree of pain, abdominal tenderness, leukocytosis etc to decide when operative intervention is needed. The association of cell-free deoxyribonucleic acid with small bowel obstruction, ischemia, and recovery supports our hypothesis and suggests that this biomarker is a potential surrogate of small bowel perfusion.